Pharmacy Practice and Pharmacotherapy: Assessment, Decisions and Monitoring
What this domain tests
This domain tests clinical reasoning: gathering subjective and objective data, identifying drug therapy problems, selecting guideline-concordant therapy, individualizing dose, and monitoring efficacy and toxicity. Expect heart failure, diabetes, asthma/COPD, anticoagulation, hypertension, infectious disease, pain, and geriatric deprescribing, always with renal/hepatic adjustment and drug-interaction check.
Core rules
- Establish goals of therapy before choosing a drug; treat the patient, not the number.
- Heart failure with reduced ejection fraction (HFrEF) uses four pillars: ARNI/ACE inhibitor/ARB, evidence-based beta-blocker, mineralocorticoid receptor antagonist (MRA), and SGLT2 inhibitor. Start or optimize all four unless contraindicated.
- Before MRA: check eGFR and potassium; avoid if eGFR <30 mL/min/1.73 m² or K >5.0 mmol/L; recheck K and creatinine in 1–2 weeks.
- SGLT2 inhibitors reduce HF hospitalization and cardiovascular death even without diabetes; they may be initiated at lower eGFR than used for glycemic control.
- Avoid NSAIDs in HF, CKD and older adults; they cause sodium/water retention and renal injury.
- Monitoring must specify parameter, timing and action: e.g., "K and creatinine at 1–2 weeks; hold MRA if K >5.5."
Worked example
A 68-year-old with HFrEF (EF 30%), eGFR 35, K 4.2, remains symptomatic on maximally tolerated ACE inhibitor and beta-blocker. Add an SGLT2 inhibitor (dapagliflozin or empagliflozin) and an MRA (spironolactone 12.5 mg daily), because eGFR 35 and K 4.2 are acceptable. Counsel on sick-day rules (hold during dehydration), genital hygiene, and volume status. Recheck K and creatinine in 1–2 weeks; if K rises above 5.5, hold the MRA, review diet and other K-raising drugs, and reassess. Do not add an NSAID for joint pain; use acetaminophen or topical therapy.
Traps
Do not start an MRA without baseline K/eGFR; do not stop a beta-blocker abruptly; do not use SGLT2 inhibitors for glycemic control alone in type 1 diabetes; do not overlook over-the-counter NSAIDs; do not document "monitor" without a parameter and timeframe; do not apply adult doses to frail elderly or renal impairment without adjustment.